EXAM 1- DMSO 1210 - Students also studied Science MedicineNursing Save

Health Assessment Exam 2 Test Bank Students also studied Science MedicineNursing Save

EXAM 1- DMSO 1210

59 terms PURPOHONTAS Preview amca study guide 100 terms quizlette2390355 Preview Professional Nursing Exam 3 91 terms laurenrbartPreview Cathete 45 terms mak Which of these statements is true regarding the vertebra prominens? The vertebra

prominens is:

• The spinous process of C7.
• Usually nonpalpable in most individuals.
• Opposite the interior border of the

scapula.

• Located next to the manubrium of the

sternum.A When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This

characteristic is:

• Observed in patients with kyphosis.
• Indicative of pectus excavatum.
• A normal finding in a healthy adult.
• An expected finding in a patient with a

barrel chest.C When assessing a patients lungs, the nurse

recalls that the left lung:

• Consists of two lobes.
• Is divided by the horizontal fissure.
• Primarily consists of an upper lobe on

the posterior chest.

• Is shorter than the right lung because of

the underlying stomach.A

Which statement about the apices of the

lungs istrue? The apices of the lungs:

• Are at the level of the second rib

anteriorly.

• Extend 3 to 4 cm above the inner third of

the clavicles.

• Are located at the sixth rib anteriorly and

the eighth rib laterally.

• Rest on the diaphragm at the fifth

intercostal space in the midclavicular line

(MCL).

B During an examination of the anterior thorax, the nurse is aware that the trachea

bifurcates anteriorly at the:

• Costal angle.
• Sternal angle.
• Xiphoid process.
• Suprasternal notch.

B During an assessment, the nurse knows that expected assessment findings in the

normal adult lung include the presence of:

• Adventitious sounds and limited chest

expansion.

• Increased tactile fremitus and dull

percussion tones.

• Muffled voice sounds and symmetric

tactile fremitus.

• Absent voice sounds and hyperresonant

percussion tones.C The primary muscles of respiration include

the:

• Diaphragm and intercostals.
• Sternomastoids and scaleni.
• Trapezii and rectus abdominis.
• External obliques and pectoralis major.

A

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate?

• Obtaining a detailed health history of the

patients allergies and a history of asthma

• Telling the patient to sleep on his or her

right side to facilitate ease of respirations

• Assessing for other signs and symptoms

of paroxysmal nocturnal dyspnea

• Assuring the patient that paroxysmal

nocturnal dyspnea is normal and will probably resolve within the next week C When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

• Between the scapulae
• Third intercostal space, MCL
• Fifth intercostal space, midaxillary line

(MAL)

• Over the lower lobes, posterior side

A The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of

tactile fremitus? Tactile fremitus:

• Is caused by moisture in the alveoli.
• Indicates that air is present in the

subcutaneous tissues.

• Is caused by sounds generated from the

larynx.

• Reflects the blood flow through the

pulmonary arteries C During percussion, the nurse knows that a dull percussion note elicited over a lung

lobe most likely results from:

• Shallow breathing.
• Normal lung tissue.
• Decreased adipose tissue.
• Increased density of lung tissue.

D

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison.

• Side-to-side
• Top-to-bottom
• Posterior-to-anterior
• Interspace-by-interspace

A When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse

interprets that these sounds are:

• Normally auscultated over the trachea.
• Bronchial breath sounds and normal in

that location.

• Vesicular breath sounds and normal in

that location.

• Bronchovesicular breath sounds and

normal in that location.C The nurse is auscultating the chest in an adult. Which technique is correct?

• Instructing the patient to take deep,

rapid breaths

• Instructing the patient to breathe in and

out through his or her nose

• Firmly holding the diaphragm of the

stethoscope against the chest

• Lightly holding the bell of the

stethoscope against the chest to avoid friction C The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis

in the lungs will reveal:

• Dullness.
• Tympany.
• Resonance.
• Hyperresonance.

A